“I’m a surgeon, but don’t ask me for surgery”

Surgeons are physicians specializing in evaluation and management of problems treated and/or cured by surgery. Cognitive (thinking) and technical (operating) skills are required. To become a surgeon, I graduated at the top of my four year college class, near the top of my four year medical school class, then apprenticed as a surgical resident days, nights, weekends, and holidays in hospitals around the United States for ten years after medical school. Many subjects are mastered, including a foundation of basic sciences such as anatomy (gross and microscopic), biochemistry, physiology (healthy function of the body), pathology (diseases), microbiology (bacteria, fungi, and viruses), pharmacology (drugs), genetics, neurosciences, psychiatry, etc. During my decade of residency, benchmarks were achieved each year to advance to subsequent higher levels of responsibility and independence. We learned about the surgical specialties, saw thousands of patients, and worked with doctors in every area of medicine. Oral and written examinations administered by the American Board of Surgery and the American Board of Plastic Surgery were passed. Training and exams were rigorous and uncompromising, designed to assess cognition (knowledge, reasoning, and judgment), technical skills, and professional ethics. All are critically important for surgery. In practice for over twenty years, I still qualify annually by reporting continuing medical education and occasionally taking maintenance of certification examinations.

Why does this matter? Because quality outcomes can only be delivered in the context of high ethical, scientific, and technical standards. Treatments we recommend should have the highest possible benefit to risk relationship: The most upside and the least downside. Because everyone is different and unique, a treatment that is beneficial for one person may be a disaster for another. To differentiate among patients what is best for one individual, we surgeons must ask questions, i.e. learn about each patient in consultation. We must examine our patients physically to know their anatomy, to understand which treatments may work best and which may not be indicated. Sometimes, we must check additional blood tests, X-rays, or other studies for more information. All that data is analyzed, options for treatment are considered, discussed with patients, and a mutually agreeable treatment plan developed. Every patient should be approached with this stepwise sequence of gathering and verifying information, analyzing the information, prioritizing possible solutions based on the presentation, finalizing a plan, and only then, implementing treatment.

As an aesthetic plastic surgeon, our office fields constant calls for this peel or that product, the latest lunchtime lift, mini-tuck, or new device, diet, or implant. Usually, callers read about it in a magazine, saw a TV show (“The Doctors”), or saw advertising. Media is a business, and media exposure is bought by business. The end game of business is sales. Sales are not necessarily about what’s best for YOU. Sales are about revenue for the manufacturer, producer, and/or marketer of techniques, devices, products, and services. We implement new information and technology in our treatments, but only as appropriate in the upside to downside calculation for each patient.

Nobody comes to us for surgery, people come for results. We specialize in results, not in procedures. Procedures are only means to an end. Often, there are several possible operations that will achieve slightly different results. Results are the solution to a problem. The problem must be properly analyzed first, and treatment solutions follow. Inquiring about solutions, whether a new product or a new procedure, before understanding and analyzing the problem is backwards.

By all means, ask about new treatments and technologies, we’ll answer your questions. As a layperson, you’re not expected to know science, biotechnology, and the human body. But you DO know, more than anyone else can ever know, what bothers you when you look in the mirror or at a photograph of yourself. You know your problem, and in our office, that’s all you need to know. We’ll discuss the rest, and decide with you which solution is the best.

The Feminine Nose: Fantastic Plastic

Does the tiny cute Disney® Princess nose exist in real life? Yes, it does, but it is indeed rare. Your nose is made for breathing, and must be large enough inside for healthy air flow with reserve capacity. Still, as the centerpiece of your face, the aesthetically pleasing nose is a reproductive advantage, and therefore natural selection favors the beautiful nose.

If nasal pulchritude is not part of your genetic inheritance, no problem: You can buy it, more reliably now than ever before. Plastic surgical techniques to feminize nasal features are better understood by doctors, including ethnic variations in anatomy. The surgical procedure to change shape and/or size of the nose is called “rhinoplasty,” (rhino = nose, plasty = to mold, to shape) and is accomplished by specialists in plastic surgery.

High speed surgical burrs soften visible angles and projections, precise instrumentation re-arranges bony support, cartilage grafts add pretty curves and inflections, and fine sutures skillfully placed bend or re-positioning cartilage. These methods are all part of the modern plastic surgeons’ armament. Rhinoplasty related deformities and irregularities that divulge surgical modification are less common because of improvements in nasal aesthetic surgery technique and because new materials are available to conceal minor imperfections. Dermal matrix, injectable fillers, and other off-the-shelf products are used as camouflage when necessary to improve the result. Most operations to beautify nasal appearance are accomplished under direct vision, the “open” approach. In the past, rhinoplasty was performed by feel and by appearance of the evolving result beneath nasal skin (closed approach).

Rhinoplasty is an operation that changes shape and size of bone and cartilage support of the nose. Your outcome results from skin re-draping over the changed underlying structures, and emerges after months of healing and slow resolution of swelling. Some maneuvers, such as narrowing the base of your nose or improving definition of finer features are accomplished by thinning or removing specific portions of nasal skin and soft tissue.

As a plastic surgeon with over twenty years of rhinoplasty experience, Dr. Steve Laverson is excited about these developments. Together, they help plastic surgeons achieve more predictable outcomes, and offer the possibility of improved lifelong beauty for many. Every woman can now have a Disney® Princess nose!

6 Ways Toward Painless Plastic (Cosmetic) Surgery

Innovative approaches for preventing and controlling pain after cosmetic surgery may be combined to help patients tolerate procedures as much as they will enjoy the result. New methods we incorporate include:

1. Surface (topical) anesthetics before skin injection: These can include Ethyl Chloride, a fine spray that instantaneously freezes the skin, overwhelming nerves that transmit pain impulses with sensation of cold so that subsequent painful stimulus is not recognized. Also, local anesthetics such as benzocaine, prilocaine, lidocaine, and tetracaine are now formulated into creams or gels that promote better penetration through your skin surface to create numbness in the area to be treated. These applications are spread over the area to be treated 20-30 minutes beforehand to allow absorption into the skin. Covering the skin with plastic wrap prevents evaporation, and may improve effectiveness. These skin anesthetics are popular before cosmetic laser and injectable enhancements.

2. Regional anesthetics: These include injection of local anesthetics to neutralize a specific sensory nerve that transmits pain from a specific area of the skin. Lips are among the most highly sensitive areas of your face and body, so this method is valuable before lip augmentation with filler. Dr. Laverson uses topical anesthetic on the skin, then carefully numbs the specific nerves that supply sensation to your lips. This allows completely pain free lip enhancement. Filler must be placed well within the substance of the lips, and topical (surface) anesthetic doesn’t penetrate deeply enough to sufficiently numb your lips without addition of a regional anesthetic to block pain impulses.

3. Cannulas for injection instead of needles: Blunt tipped fine sterile cannulas are now marketed to allow distribution of cosmetic injectables within the face or body without painful needles. These cannulas offer the added benefit of avoiding nerve or blood vessel injury. Sharp needles more easily cut small nerves and vessels beneath the skin, leading to bruising and other side effects. Blunt tipped cannulas, when carefully used, are more likely to push aside these structures, allowing injection to proceed with less trauma to surrounding tissues.

4. Long acting local anesthetics: Use of injectable anesthetics and/or anesthetics to moderate pain for as long as three days after surgery is available thanks to Pacira Pharmaceuticals’ introduction of Exparel®. Now FDA approved, this long acting local anesthetic (bupivacaine) is packaged biochemically as a “liposomal suspension” (within tiny lipid globules) for slow release. Exparel® can be distributed within your tissues before surgical closure. While not totally eliminating post-surgical pain, your discomfort may be reduced to a much more tolerable level. Use of Exparel® may diminish your dependence on narcotic analgesics such as morphine, oxycodone, meperidine, hydromorphone, and hydrocodone, all of which have undesirable side effects.

5. Nausea prevention: One cannot discuss advances in pain control without mentioning nausea prevention. The classically most effective analgesics are narcotic medications which promote nausea, easily their most miserable side effect. First off, if you are nauseated after rhinoplasty, breast implants, or tummy tuck, you’re unable to hold down pain medicine. You’re not only nauseated, but in pain, a difficult combination. Second, if you’re vomiting after nose, face, breast, or liposuction surgery, the entire experience of aesthetic enhancement becomes tainted with bad memories. We plastic surgeons want to prevent nausea and vomiting as much as possible, knowing that if you are miserable, you’re less likely to come back for more. The introduction of anti-nausea medications such as ondansetron (Zofran®), aprepitant (Emend®), scopolamine skin patch (Transderm SCOP®), and alvimopan (Entereg®) combined with traditional anti-nausea treatments droperidol, metoclopramide, and others offer much improved pain control by narcotics and a better surgical experience.

6. Finally, discovery and use of non-narcotic analgesics are helping. Intravenous acetaminophen (Ofirmev®) given toward the end of major surgery, ketorolac (Toradol®) in the recovery room, and tramadol extended release (Ultram® ER) at home to supplement narcotic medications offer significant relief with minimal side effects. Also, muscle relaxers such as Carisoprodol (Soma®) are useful.

Still Talking About Her Fifty One Years Later

Marilyn Monroe had plastic surgery

Wow. Marilyn Monroe wasn’t born that way. Medical records and X-rays of the Hollywood legend to be featured in a Beverly Hills auction next month show evidence of plastic surgery. The actress likely had a cartilage chin implant, as well as rhinoplasty (aka a nose job) on the tip. The memorabilia came from her plastic surgeon, Dr. Michael Gurdin, reports The New York Daily News. Monroe, 36, was found dead at her home on Aug. 5, 1962, of acute barbiturate poisoning.

Rhinoplasty, The Gift that Keeps Giving

There are two general categories of aesthetic procedure, those that recreate your look by eliminating aging features, and those that change your look by changing inborn features that may be “improved.” Among the latter, rhinoplasty is the flagship procedure. By beautifying the central feature of your face, for the rest of your life, you will benefit daily, and in every situation. Rhinoplasty is a delicate surgical procedure. Enhancement may be significant with only millimeters of change. The human eye is very sensitive to slight adjustments of angle and proportion.

Interested men and women should seek advice only from well trained and appropriately certified surgeons. In the United States, this includes either a surgeon certified by the American Board of Plastic Surgery or perhaps a “facial” plastic surgeon with a library of “before and after” photos demonstrating a track record of successful results. The procedure should be performed in the safest possible environment, at an accredited free-standing ambulatory surgery center or office operating facility. Patients should not hesitate to challenge surgeons regarding credentials. The qualifies surgeon works hard to provide the best circumstances for his or her patients, and is usually proud to show evidence of certifications achieved.

There is no single method or technique of rhinoplasty. For each individual, the procedure is adapted in scope and magnitude to accomplish goals established by patient and surgeon in advance. The result should not be left to the surgeon’s discretion, and should not in any way be a surprise to the patient. Changes to the nose are agreed upon in advance. Both the precise change and the degree of change are discussed. Although there is always an element of unpredictability and swelling and healing occur during several months following nose re-shaping, the overall outcome should match ethnicity, enhance other facial features, and appear naturally in harmony with the remaining facial contours. For example, if the patient is Asian or Hispanic, the nose should not appear obviously caucasian. For women, reduction in nasal size and enhancement of delicacy of the nose enlarges the relative size of eyes and lips, enhancing femininity.

The younger the age at which rhinoplasty is performed, the longer the patient experiences resulting benefits. Because facial growth is not complete until late teens, rhinoplasty should be deferred until age 16 or later for women, and 18 or later for men.

Steve Laverson, MD, FACS

Diplomate, American Board of Surgery and American Board of Plastic Surgery

Member, American Society of Aesthetic Plastic Surgeons and American Society of Plastic Surgeons